Womens Health EOR Study Guide Part 3

Breast CA •MCC of non-skin cancer in women •2nd MCC cancer death in women (after lung CA) Risks: •personal history •(+) FHX: -1st degree relative: 2x risk -2nd degree relative: 3x risk •Genes: BRCA1 & BRCA 2 -BRCA 1: higher risk -BRCA 2: lower risk •Nulliparity •First full-term pregnancy >30 •Early menarche (before 12) •Late menopause (after 50) •increasing age •Postmenopasual HRT •Hx uterine CA *most arise from intermediate ducts and are invasive Types: •infiltrative ductal carcinoma (MC) -lymphatic metastases •infiltrative lobular carcinoma •pagest disease •inflammatory Clinical Presentation •painless breast mass *>5cm suspicious •hard, fixed, irregular margins, nonmibile •upper outer quadrant *due to more tissue in that area Exam: •skin changes: erythema, discoloration, ulceration, skin retraction (Coopers ligament), bloody discharge •Palpation of regional lymph nodes: axillary, pectoral, supraclavicular, infraclavicular, subscapular, epitrochlear and lateral chain •axillary lymphadenopathy •mets: bone, lungs, liver, brain Mammography: women >40 *can detect cancer as early as 2 years •microcalcifications & speculated •Most diagnosed after abnormal test Hormone Receptor Sites •ER (+) tumor: slightly lower liklihood of early recurrence •Er (-): mets to liver, lung, brain *higher chance of recurrence Ultrasound: women <40 MRI: rapid uptake of contrast Biopsy: •FNA: removes the least amount of tissue, but will not allow for receptor testing •Core Biopsy: takes more tissue, but allows for receptor testing •Open Biopsy: MOST ACCURATE Genetic Testing •considered for members of high risk fhx •genetic counseling needed before and after Screening: Mammogram every 1-2yrs women 50-69 •ACS: CBE q3yrs 20-39, mammo + CBE age 40 •ACOG: CBE + mammo q1-2yr 40-50, yearly 50+ •USPSTF: mammo +/- CBE q1-2 yrs, age 50-74 (+) ER: •Anastrozole (postmenopausal) •Tamoxifen (premenopausal) *prevention in high risk family history •Trastuzuma (anti-HER2) Radiation: usually done after lumpectomy or mastectomy Surgery: Radical mastectomy: •removal of breast, pectoral muscles, axillary lymph nodes Modified radial mastectomy: •removal of breast and underlying pectoralis major fascia Breast Conservation: excise tumor with negative margins, lymph biopsy •stage I & II and some III Follow-Up: •Close follow-up needed due to high risk of recurrences •exam Q 4 mo x 2 yrs, then Q 6 mo x 3 yrs, then yearly •Mammogram 6 mo after radiation then becomes yearly Woman Exam •age-appropriate reproductive health info •no pelvic exam unless symptomatic or STD screen needed Pelvic and Pap Smear (Age 21) •do NOT need pap in asymptomatic patient <21yo even if sexually active •pelvic exam: annually •pap smear: varies on findings •do not need to do pelvic before prescribing birth control Clinical Breast Exam (CBE) •every 1-3 years for women 20-39 years old •yearly and mammograms in 40+ •do NOT take place of mammogram Routine Screening OBGYN Cervical reduce embarrassment •Inspect in all four positions - Sit up right - Hands on hips - Leaning forward - Lying down •Palpate all 4 quadrants & Tail of Spence •Palpate for regional LAN •SBE no longer recommended Step 1: •obtain cervical scraping from complete squamocolumnar junction by rotating 360 degree •compress uterus and adnexa Step 2: •saline-soaked cotton swab or small brush into the endocervical canal and rotate 360 degrees Rectovaginal •Insert well-lubricated middle finger into rectum and index finger into vagina New Method: ThinPrep Testspatula/brush/broom •Cervix: 3-4cm diameter and moderately firm, mobile, without undue discomfort •raise cervix toward anterior abdominal wall and palpate uterosacral ligaments •Fecal occult blood test False readings: •wrong type of lubricant: interfere with cell prep •infections: BV, G/C •not getting a good cell sample False readings: •obesity •uncomfortable, rigid, guarding Comprehensive Skin Exam •USPTF: no recommendation Pap Smear Screening STD Screening High Risk Breast/Colon •Start cervical CA screening at age 21 Pregnant Women: •Young (15-24) Mammogram+/- CBE •Ages 21-29: pap every 3 years •Hep B, HIB, Syphillis: ALL •African American ACS, ACOG, AMA: •G/C: <25yo or high risk •Unmarried -Yearly age 40 •ACS: every 3 years for pts 20•Ages 30-65: Pap + HPV every 5 years •Hep C: high risk •Low socioeconomic 40 and yearly 40+ ( or pap every 3 years •New partners in past 60 USPSTF, WHO: Nonpregnant Women: days -Biennial at age 50 •UV Protection: SPF 15+ •Age >65: stop screening if… •ALL sexually active women •Mult. partners -Discontinue after 74yo -no hx of moderate/severe should receive HIV, G/C yrly •HX STI Risks: dysplasia or cancer AND 3 (-) paps •Illicit drugs Colon: •suspicious moles or lesions in a row or 2 (-) PAP +HPV results •high risk: HIV, HSV, syphilis, •Admission to Low risk: •hx skin CA (personal or fhx) in a row in past 10 yrs trichomoniasis, Hepatitis B & correctional •Yearly at 50+ or sDNA •atypical moles C •Internet partner every 3 years •hx extensive sun exposure •Sex workers •50+ total moles •Don’t screen sexually active High risk: refer women 25+ if not high risk •D/C after 75 Risks Risk Factors: HPV HPV & Cervical Dysplasia: Dysplasia CIN I: mild cervical dysplasia Cancerous Bethesda System Dysplasia/ Cancer Sexual Activity Factors: •multiple sexual partners •early onset of sexual activity •high-risk sexual partner •HPV present in >80% of all CIN •HPV 16: 50-70% HPV 18: 7-20% *cigarettes have a synergistic effect with HPV cancer •LOWER 1/3 of epithelial lining CIN II: moderate cervical dysplasia •LOWER 2/3 of epithelial lining Atypical Squamous Cell (ASC-US/H) •undetermined significance, cannot exclude high grade lesion Infection Factors: •HPV infection (BIG ONE!) •History of sexually transmitted infection •Immunosuppression (HIV) High Risk: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68 CIN III: severe cervical dysplasia •over 2/3 of epithelial lining; FULL thickness Low-Grade Squamous Intraepithelial Lesion (LGSIL/LSIL) corresponds to CIN-1 Others: •multiparity •long term OCP use Pap Smears •21-29yo: every 3 years •30+: HPV + pap q5y or pap only q3y •30+/+HPV: pap&HPV 1yr or genotype •>65: stop if no hx dysplasia or CA, 3 (-) paps or 2 (-) pap + HPV in a row in last 10 years •High-risk HPV test performed after abnormal Pap •Most + do NOT develop CIN or CA Vaccines: Gardasil 9 (6, 11, 16, 18, 31, 33, 45, 52, 58) •female: age 11-26, male: age 11-21 •<15yo: 2 doses, 6 months apart •>15yo: 0, 2, 6 months *min interval b/w 1st and 2nd 4 weeks, b/w 2nd and 3rd is 12 weeks Atypical Screening 3 options: 1. repeat serial cytology: every 6 months until 2 consecutives normal -second abnormal colposcopy 2. High-risk HPV: colposcopy if + 3. Immediate referral to colposcopy Before repeat, treat the underlying: •hormones if atrophic vaginitis •antimicrobials for infections LSIL, HSIL, ASC-H, AGC Colposcopy ALWAYS treat CIN II and III except: •pregnant woman (wait till postpartum) •CIN II in adolescents (high chance of spontaneous regression) High-Grade Squamous Intraepithelial Lesion (HGSIL/HSIL) corresponds to CIN II and III excision (LEEP) or ablation Atypical Glandular Cells (AGC) Glandular cells: normal components of the endocervix secrete mucus Atypical: dont match normal glandular cells but are not definitely cancer Colposcopy After Colposcopy Illuminated low-power magnification CIN I: expectant -3-5% aqueous acetic acid solution •high chance of regression -directed biopsies of abnormal areas •2 paps every 2 months or… -curette or brush of endocervical canal Pap + HPV at 6 months •repeat if abnormal cytology or HPV+ Indications: •if all normal, then routine screening •abnormal cytology or HPV test •clinically abnormal cervix Surgery: •unexplained intermenstrual or •CIN II/III postcoital bleed •Invasive Cancer •vulvar or vaginal neoplasia •Otherwise abnormal or unsatisfactory •history of in utero DES exposure colposcopy Cryotherapy: office procedure: nitrous oxide or carbon dioxide over ENTIRE lesion - pros: easy to use, low cost, low risk; cons: f/u colposcopy can be unsatisfactory - SE: cramping, copious watery discharge for week Carbon Dioxide Laser: destroys tiuuse with narrow zone, depth of 7mm - Pros: precise, in office or outpatient hospital; cons: local anesthesia, expensive, training - SE: pain, discharge, bleeding Loop Electrosurgical Excision Procedure (LEEP): small fine wiare loop attached to electrosurgical generator *CIN II and III - Pros: easy to use, tissue histology, in office with local; cons: increased risk premature delivery in pregnancy - SE: cramping, bleeding (1 week), discharge (3 weeks) Cold Knife Conization: excision of cone-shaped postion of cerix with scalpel - Pros: histology; cons: expensive, done in OR, increaserd risk premature delivery - SE: cramping, bleeding, discharge OBGYN About Clinical Presentation Diagnostics Cervical Types: •asymptomatic in early stages •colposcopy with biopsy Management Carcinoma in situ (stage 0) Cancer •squamous cell (MC!) •adenocarcinoma •clear cell (linked with DES) Spread: •paracervical nodes (MC) •parametrial, obturator, hypogastric, external iliac, sacral Risks: •HPV (16, 18, 31,33) •early sexual activity, STIs •lots of sexual partners •smoking, DES expsore •cervical intraepithelial neoplasia •immunosuppression OBGYN Ovarian Cancer About Types: Epithelial ovarian cells (MC!!!) •repeated epithelial trauma/repair •near menopause •serous cystoadenocarcinomas •assocciated with CA-125 Germ cell tumors: 20-30yo •AFP, hCG, LDH Sex Cord Stromal Tumors •estrogen & andogrens •granulosa cell tumors (inhibin) Risks: •(+) FHX (strongest risk) •increased age, white •early menarche, late menopause •endometriosis, nulliparity •smoking, obesity, talcum powder •post-coital bleeding or spotting •irregular, heavy vaginal bleeding or watery discharge •weakness, weight loss, anemia, pelic pain *late symtoms About •excision (LEEP, cold knife) •ablation (cryotherapy, laser) •total abdominal hysterectomy + bilateral salpingo-oophorectomy Stage 1A: total hysterectomy or radical Stage 1A2, 1B, IIA: •radiaction with brachytherapy •radical hysterectomy with bilateral pelvic lymphadenectomy Exam: cervical discharge or ulceration •early: cervix normal •late: enlarged, irregular, firm Cervix Endophytic: barrel-shaped Exophytic: friable, bleeding, cauliflower Locally advanced (IIB, III, IIVA): •radiation + chemo Advanced: radiacation, chemo Clinical Presentation Early: poorly defined or vague •GI: bloating, abdominopelvic pain, early satiety, indigestion •GU: frequency, urgency, dyspareunia •Other: fatigue, back pain Late: •early symptoms •increased abdominal girth (ascites) •nausea, anorexia •dyspnea (pleural effusions) Exam: •solid, fixed irregular adnexal mass •unilateral cystic masses •abdominal distention, upper abd mass •lymphadenopathy: sister mary joseph *mets to umbilical lymph nodes REDUCE RISK •OCPs, progesterone therapy •breastfeeding, tubal ligation, hysterectomy/salpingectomy Neoplasms CIS or pap abnormal: conization Diagnostics Genes: Breast-Ovarian Cancer Syndrome •BRCA 1 & BRCA 2 •MC in women of Ashkenazi Jews, French Canadian, Icelandic Hereditary Nonpolyposis Colorectal Cancer Syndrome: high risk of colon, breast, endometrial CA Management EOC CANCERS Surgical: required unless pt cannot tolerate •definitive diagnosis and staging •removal of tumor and contralateral adnexa; often hysterectomy & infracolonic omentectomy Medical: Chemo 4-6wk post-surgery CA-125: elevated in 50% •useful in postmenopausal but not premenopausal women •normal does NOT exclude CA •younger pts: AFP, LDH, hCG USE CA-125 TO MONITOR PROGRESS HE4: similar sensitivity to CA-125 GERM CELL CANCERS Pelvis US: solid, septation, ascites •delineate benign or malignant *INITIAL TEST Surgical: •diagnosed at earlier stage then EOC •removal of involved adnexa CT or MRI: characterize details Medical: curable in most cases •chemo and radiation can be helpful •prophylactic bilateral salpingooophorectomy in women with genetic predisposition *better to do by age 35 Biopsy: DEFINITIVE DX Presentation Diagnostic Treatment Preinvasiv e Vulvar Disease •vulvar intraepithelial neoplasia (VIN) associated with multifocal lower genital tract disease -younger: VIN MC, median age: 40yo •white, hyperkeratotic papules •vary in color-white to velvety red or black •MC SYMPTOM: pruritis colposcopy with biopsy •suspicious lesions GOLD STANDARD Risks: HPV, HIV, smoking Follow-up: pelvic exam with colposcopy q3-4mo until pt is disease free for 2 years •Wide local excision + vulvectomy Prognosis: high chance for recurrence (-) node mets: good prognosis (+) node mets: almost always fatal Pagets Disease •Intraepithelial neoplasia of vulva (adenocarcinoma in situ) • mostly confined to epithelium -perirectal, butt, thigh, inguinal MC: pruritis, vulvar soreness •pruritic, slow spread, velvety-red •”Red Velvet Cake” •eventually becomes eczematoid with maceration and development of white plaques Vuvlar Cancer Types: •90% squamous cell carcinomas •2nd MC: malignant melanoma •vulvar pruritis and/or mass •bleeding or vulvar pain •mass on exam •remove all tumor wherever possible •wide radical local excision with inguinal lymph node excision •1/3 are midline or bilateral vulva SCC: arise in labia MC Exam: •red, white ulcerative or raised crusted lesion •large, exophytic, cauli-flower like to small ulcers to elevated red velvety tumor necrosis •pelvic exenteration: anus, rectum, rectovaginal septum, urethra or bladder Risks: •poor and elderly, infrequent exam •HPV 16 & 18 (younger) •chronic inflammation (older) Vulvar Biopsy Treatment based on biopsy •wide local excision, laser ablation •topical 5-FU, Imiquimob •superficail vulvectomy •chemo: depends on CA extent and type Follow-up: every 3 mo for 2 years •80% recurrences in 2 years Neoplasms Preinvasiv e Vaginal Disease About •vaginal intraepithelial neoplasia (VAIN) •single, or multifocal (MC) •MC in upper 1/3 vagina •hx similar to cervical neoplasia (CIN) -possible treated for CIN VIN -smoking & HPV increases risk Presentation Diagnostic •abnormal cytology or as a visible lesion Colposcopy and biopsy •condylomatous lesions usually -3-5% acetic acid solution associated with dysplasia •lesions usually on vaginal ridges, may be raised and have spicules Vaginal Cancer •VERY RARE •cervix is uninvolved or minially •MC form of vaginal malignancy is extension of cervical cancer *secondary tumor •Postmenopausal, postcoital bleeding •may see discharge, mass, urinary sx •MC site: labia majora, labia minora Types: •SQUAMOUS CELL: posterior upper 1/3 of vagina •adenicarcinoma: younger patients •sarcoma: highly aggressive in infancy •melanoma Risk: smoke, HPV, mult. partner, DES •colposcopy biopsy: acetic acid or toluidine blue application may help Treatment VAIN I: regress, do not require tx VAIN II/III: surgical excision or carbon dioxide laser *may use 5-FU •if extends to upper 1/3 vagina, can be removed at time of hysterectomy •monitor every 5-6 months •hysterectomy, vaginectomy, lymphadenectomy -local invasion: pelvic exenteration Exam: red or white ulcerative or raised crusted lesion •melanoma is aggressive and do not respond well to therapy Sarcoma •polypod, edematous “grape-like” masses at vaginal introitus 5-year survival: •77% stage I •45% stage II •31% stage III •18% stage IV OBGYN Endometrial Hyperplasia About •endometrial gland proliferation with cytologic atypia •precurose to endometrial cancer Risks: •prolonged unopposed estrogen •chronic anovulation •estrogen only therapy •PCOS, obsess, perimenopause •early menarche, late menopause •Tamoxifen, lymch syndrome Endometrial Cancer •MC GYN malignancy •MC in postmenopausal •estrogen-dependent cancer *estrogen stimulate endometrium Types: •adenocarcinoma (MC) •serous *older patients, poor prognosis •clear cell *aggressive Risks: high estrogen exposure, obese, PCOS, E-only HRT, Tamoxifen, DM BREAST DISORDERS Clinical Presentation Diagnostics •abnormal uterine bleeding TVUS: thickened endometrial stripe >4mm (menorrhagia, metrorrhagia, postmenopausal bleeding) Endometrial Biopsy: DEFINITIVE •if >35yo, increased endometrial stripe, unopposed E, Tamoxifen, persistent bleeding with thick stripe •abnormal uterine bleeding (postmenopausal bleeding!) •abnormal vaginal discharge •lower abd cramps Reduce Risk: •COCs, smoking TVUS: thickened endometrial stripe >4mm Endometrial Biopsy: DEFINITIVE *D&C more definitive due to larger tissue sample Treatment Hyperplasia WITHOUT Atypia •Progestin (oral or IUD) •repeat biopsy in 3-6 months Hyperplasia WITH Atypia: •total abdominal hysterectomy Stage I: total abdominal hysterectomy *younger, more favorable Stage II-III: TAH-BSO + lymph *older, poorer prognosis •CA-125 elevated in 20% of stage I StageIV: systemic chemo Breast Female Breast •Secondary reproductive gland -arises from ectoderm components •glands & ducts organized into lobes •stroma (fibrous tissue) to bind lobes •Adipose tissue within/between lobes Breast Development and Physiology •Each breast: 12-20 lobes base: near ribs •80-85% of normal breast: adipose •Apex: contain major excretory duct for the lobe *closer to the nipple •nonpregnant/nonlactating: small, tightly packed alveoli •Each lobe: group of lobules “pedal” w/ several ducts which unite to form the major duct for the lobe “flower” -each major duct widens to form ampulla then narrows as its ind. opening in the nipple -usually only 6-8 opening visible on nipple surface -areola also contains sebaceous glands (Montgomery glands) which may be visible punctuate priminences •pregnant: alveoli hypertrophy and lining cells proliferate Female Breast •Fetal and Prepubertal Breast •Fetal: primordial breast arises from basal layer of epidermis •Prepubertal: rudimentary bud -few branching ducts -ducts are capped with alveola buds, end buds, or small lobules Lactation Changes: •rapid drop in E and P postpartum •breasts fully mature and secrete milk -drop in P triggers milk production -prolactin is main regulator of milk production •after nursing ceases or if estrogens are given, breast rapidly returns to pre-pregnancy state -decreased cellular elements and increased adipose tissue OBGYN Mastitis About •seen with lactation and •lactation: alveolar walls secrete lipids and proteins (milk) Lymph Drainage •dermal, subderma, interlobar, and prepectoral systems •MOST drain into axillary nodes -receive most lypmphatic drainage \ therefor are MC site of breast cancer mets *Sentinel nodes Alternate pathway: internal mammary, supraclavicular, epitrochlear, contralateral axillary and abdominal lymph nodes •Deep surface of breast lies on fascia that covers the chest wall muscles -fascia is condensed into multiple bands (coops ligaments) support breast in upright position Puberty and Breast •Age 10-13: E/P effect breast tissue -communication between epithelial and mesenchymal cells -extensive branching of ductal system and lobule development Menopausal and Postmenopausal Pregnancy Menopausal changes Pregnancy Changes •decrease in estrogen and progesterone •final breast tissue differentiation •Breast will atrophy and involution occurs under the influence of -Low # and size of ducts & acini progesterone and prolacting and -Eventually regress to almonst is NOT complete until first fullinfantile state (breast tissue, but still term pregnancy •Overall growth: increased acinar tissue, have adipose) •marked increase in breast size ductal size & branch, adipose deposits -Adipose tissue may or may not and turgidity atrophy •deepening pigmentation of the •Nipple & areola enlarge w/ puberty -Parenchymal elements lost nipple-areola complex -smooth muscle fibers surround base of (functional tissue) •nipple enlargement nipple •areolar widening with increased -nipples sensitivity to touch increases Postmenopausal: breast epithelial cells number and size of lubricating undergo programmed cell death at the glands Premenstrual: breast epithelial cells end of the luteal phase when E and P •branching and widening of breast proliferate during the luteal phase when levels decline ducts E & P are increased -decreased size and turgor •increased acini -acinar cells increase in # and size -reduced number and size of breath -ductal lumens widen acini Late pregnancy: fatty tissue are -overall increase breast size and -decreased diameter of ducts almost completely replaced by *cyclic menstrual breast changes are turgor cellular breast parenchyma -frequently see observable increase in very variable breast fullness and tenderness *1 week before menses Presentation Classic: Treatment •Antibody-coated bacteria in milk supports Congestive Mastitis •bilateral breast enlargement 2-3 nursing •typically primigravida nursing patients *1st pregnancy •rare prior to 5th day postpartum Bug: S. aureus •RARE if patient is not nursing and no other cause (radiation) Breast Abscess •MC in lactating, primigravida Bug: S. aureus OBGYN Fibrocystic breast Chnges (Glandular Hyperplasia) •painful erythematous lobule in outer quadrant of breast noted during 2nd or 3rd week of puerperium •unilateral breast pain, tenderness, warmth, swelling, induration •cracked nipples or fissures •Abscess: pitting edema and fluctuation •May arise from pre-existing mastitis •red, mass, pain, fluctuance, induration About •MCC cyclic breast pain in reproductive age women •MC age 30-50 years *stop after menopause unless HRT Pathophysiology: •hormonal imbalance that may produce asymptomatic breast lumps •estrogen considered factor •possible increase if drink alcohol •caffeine can worsen pain Fibroadenoma •Common, benign solid tumor •focal abnormality of breast lobule •young women Clinical Presentation •Mass with pain or tenderness •pain secondary to proliferation of normal glandular tissue *can increase and decrease size •usually present or worse during premenstrual phase (prior to menstruation) Exam: •multiple, nodular, mobile, smooth round lumps in both brests diagnosis *look under microscopy days postpartum due to milk stasis Treatment •avoid milk stasis continue breastfeeding *wont hurt baby to feed •local heat warm compresses, well-fit bra •instruct on proper breastfeeding techniques •ABX x10-14d -Dicloxacillin, Naficillin, Augmentin -Cephalexin, Clinda, Erytho, Bactrim -Severe: inpatient IV with Vanc or Clinda Clinical Presentation: •bilateral breast pain and swelling Non-peirpheral: peripheral, subareola; Peripheral: skin infection Subareola: due to keratin-plugged milk ducts behind nipple *multiple abscesses I&D with ABX Management: •drainage (manually or pump) •if do not want to breastfeed: ice pack, tight-fitting bras, analgesics, drainage Diagnostics Treatment •US or •reassurance of benign findings mammogram •avoidance of trauma, well-fitting, supportive bra *no mammogram if •abstaining from caffeine, coffe, chocolate <30yo •OCPs can reduce symptoms FNA: •straw colored or green fluid (no blood) •CAM: evening primrose oil, vit E 400U •OTC analgesics: Tyneol, Ibuprofen •severe pain: Danazol, Tamoxifen •Refractory: surgery Prognosis: exacerbation may occur until menopause •estrogen stimulates ducts, progesterone stimulates stroma •Round, firm, discrete, mobile, nontender mass •may enlarge with pregnancy •does not change throughout cycle •more frequent and earlier age of onset in black women Pathophysiology: •suspected possible hormonal link •increased in size during pregnany and with estrogen therapy •decrease in size after menopause LABOR AND DELIVERY COMPLICATIONS- preterm labor •clinical US: solid, wellcircumcised, avascular mass Core Biopsy: DEFINITIVE •May be confused with Phyllodes tumor: a fibroepithelial tumor that clinically resemble fibroadenomas and has a small chance of malignancy surgical excision Unclear diagnosis or rapid growth: surgery •excision with margin of normal tissue Asymptomatic: monitor, core needle biopsy to confirm OR repeat US and breast exam in 3-6 months Shoulder Dytocia About Presentation Complications •failure of shoulder to spontaneously travers •turtle neck sign Maternal Complications: the pelvis after delivery of the fetal head retraction of babys •perineal or vaginal tears due to impaction head: or red, puffy face •postpartum hemorrhage •anterior shoulder stuck behind pubic bone •uterine rupture Risks: •macrosomic infants of diabetics •post-term pregnancy, prolonged 2nd stage •multiparity •forceps during delivery •maternal obesity, advanced age •epidural anesthesia Breech •presenting part is the buttocks and/or feet Types: •Frank: hips flexed, knees extended •Complete: hips and knees flexed •Incomplete: one or both hips not ocmpeltely flexed Umbiclica l Prolapse •cord extends past the presenting part of the fetus and protrudes into the vagina •can cause low fetal O2 due to umbilical artery vasospasm or vein occlusion Uterine Rupture •complete transection of the uterus from endometrium to the serosa •life-threatening to mother & fetus Risks: previous rupture, prior C-section Decreased Risk: prior vaginal delivery OBGYN PROM/ PPROM Management Nonmanipulative: •Mcroberts Manuever: hyperflexion and abduction of mothers hips Fetal Complications: •brachial plexus injuries: erbs palsy, klumpke paralysis, cerebral palsy •erb-duchenne palsy: C5-C6 “waiters tip” deformity (arm adducted, elbow extended, forearm pronated, wrist flexed, finger curles) •fracture: clavicular, long bone •anoxic brain injury, death Exam: soft mass instead of normal hard surface of the skull Complications: •developmental dysplasia of hip •torticollis •mild deformation Manipulative: delivery of posterior arm •woods corkscrew maneuver: rotation of fetal shoulder 180 degrees Others: •gaskin four maneuver •zavanelli maneuver: pushing head back in •external cephalic version before labor if successful; C-section is unsuccessful •planned C-section US: confirm diagnosis if uncertain •tral of labor and vaginal breech birth for low risk of complications •sudden, severe proonged fetal bradycardia or variable deceleration Risks: •low birth weight, premature, malpresentation •long umbilical cord •pelvic deformities •low-lying placenta, polyydraminos EMERGENCT C-SECTION •sudden extreme abdominal pain •decreased/absent uterine contractions •abnormal bump •vaginal hemorrhage Fetal HR: bradycardia MC IMMEDIATE laparotomy & fetal delivery •followed by uterine repair About Rupture of amniotic membrances before the onset of labor (<37 weeks) Clinical Presentation •GUSH OF FLUID or persistant leakage of fluid from the vagina Risks: STIs, smoking, prir preterm delivery, multiple gestations Complications: •chorioamnionitis •endometriosis Uterine Dehiscence: peritoneum intact Diagnostics Sterile Speculum Exam: •pooling of secretions in posterior fornix Nitrazine paper test: turns blue if pH >6.5 Fern Test: amniotic fluid-dry fern pattern (crystallization of estrogen and amniotic fluid) US: check amniotic fluid index *if uterus repaired, all future pregnancies will be a C-section Treatment Expectant: admit with monitoring, await labor Labor induction: if no labor within 18 hours then give Prostaglandin cervical gel or Oxytocin <37 weeks (PPROM): •Betamethasone (< 34 weeks) •ABX (Ampicillin + Azithromycin) •tocolytics to delay delivery Normal fetal heart rate is between 120-160 bpm  > 160 for 10 minutes fetal tachycardia  < 120 for 10 minutes fetal bradycardia Nonstress testing - the nonstress test is a simple, noninvasive way of checking on the baby's health. The test records movement, heartbeat, and contractions. It notes changes in heart rhythm when the baby goes from resting to moving, or during contractions if the mother is in labor  GOOD- Reactive NST - > 2 accelerations in 20 minutes defined by increased fetal heart rate of at least 15 bpm from baseline lasting > 15 seconds, indicates fetal well being  BAD - Nonreactive NST - no fetal heart rate accelerations or < 15 bpm increase lasting < 15 seconds, if this is the case then get a contraction stress test Contraction stress test - measures fetal response to stress at times of uterus contraction  GOOD - Negative CST - No late decelerations in the presence of 2 contractions in 10 minutes, indicates fetal well being, repeat CST as needed  BAD - Positive CST - Repetitive late decelerations in the presence of 2 contractions in 10 minutes, worrisome especially if nonreactive NST, prompt delivery